Analysis Bridge Resource Management Verbal exchange between the wheelsman and the master was misinterpreted by both. With the vessel moving in the wrong direction, the available instruments such as the rudder angle indicator, radar, and ECS (which may have helped detect the wrong course) were not consulted. It was not until the wheelsman volunteered that he thought that the vessel was on the wrong heading that the master ordered a course correction, which nonetheless failed to prevent the grounding. Master's Work/Rest Periods In Canada, there exists a set of well-established regulatory requirements11 serving as safety guidelines to help masters and officers avoid the risks associated with fatigue. Nonetheless, these were not incorporated in the company's written procedures. In this occurrence, some features of the master's work/rest schedule fall short of the minimum acceptable levels identified in the requirements. For example, a minimum of six consecutive hours of rest in a 24-hour period12 is considered necessary, whereas the master had only four and a half hours of rest between 2300on October25 and 0330the next morning. In addition, a total of at least 16hours of rest during any 48-hour period is a minimum requirement and the master had rested for a total of 13.5hours in one of the two 48-hour periods under review.13 On 25 October 2005, the master was on duty for 15.5consecutive hours and overnight between 26and 27October, he worked another 15consecutive hours. At the time of the accident, he had been on duty for nine consecutive hours. Although he had 19hours of rest in the 48hours immediately before the occurrence, it is unclear how many of those hours were spent in sleep. Taking into account the master's 15.5-, 15-, and 9-hour periods over three days and one instance of having rested for fewer hours than the minimum set out in the established guidelines, this schedule may have predisposed him to fatigue-related performance issues. It is critical that crew, officers, and masters occupying safety-sensitive positions have adequate rest periods between work shifts as required by safety regulations. Otherwise, resulting fatigue could degrade performance and adversely affect safety. The grounding occurred when the vessel crossed to the channel's southeasterly limit. The vessel had turned to the south when a miscommunication occurred between the bridge team, resulting in an incorrect helm application. The incorrect heading was not detected in a timely manner because the rudder angle indicator was not sighted by the master and navigation instruments such as radar and electronic chart system (ECS) were not used to their full potential. Despite the critical nature of the navigation at hand, the master was the sole officer carrying out all navigation and communication duties. The master's work/rest schedule for October25 and 26did not adhere to well-established regulatory requirements.Findings as to Causes and Contributing Factors The grounding occurred when the vessel crossed to the channel's southeasterly limit. The vessel had turned to the south when a miscommunication occurred between the bridge team, resulting in an incorrect helm application. The incorrect heading was not detected in a timely manner because the rudder angle indicator was not sighted by the master and navigation instruments such as radar and electronic chart system (ECS) were not used to their full potential. Despite the critical nature of the navigation at hand, the master was the sole officer carrying out all navigation and communication duties. The master's work/rest schedule for October25 and 26did not adhere to well-established regulatory requirements. The regulatory requirements to help ensure masters and officers have enough rest were not incorporated in the company's written procedures.Finding as to Risk The regulatory requirements to help ensure masters and officers have enough rest were not incorporated in the company's written procedures. The use of the monochrome option for the ECS in conjunction with the night display presentation and the red transparency placed over the screen resulted in a reduction of chart, course, and vessel-position details. The master's schedule may have predisposed him to fatigue-related performance issues.Other Findings The use of the monochrome option for the ECS in conjunction with the night display presentation and the red transparency placed over the screen resulted in a reduction of chart, course, and vessel-position details. The master's schedule may have predisposed him to fatigue-related performance issues. Safety Action Action Taken Transport Canada Transport Canada Marine Safety Ontario Region is implementing a monitoring programme for2008. Elements of this programme, that will be applicable to all domestic vessels on a random sampling, will include the following: verification of crewing levels as per the Safe Manning Certificate; checking of master's log of crew members' hours of work and hours of rest; vetting all crewing certificates including Marine Emergency Duties for non-certificated crew; and checking the validity of the crew members' medical certificates.